Journal of Nursing Education

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Problems in the Development, Use and Testing of Nursing Theory

Janet L Engstrom, RN, CNM, MS

Abstract

ABSTRACT

This paper identifies and describes seven areas of difficulty in the development, use, and testing of nursing theory. These problems are as follows: (1) the belief that there are absolute truths about nursing and that these truths can be found; (2) a lack of understanding of the definition and functions of theory; (3) the notion that there is only one theory of nursing and that this theory can account for all nursing activities; (4) the belief that members of the profession must all agree on the theory or theories that should be used; (5) the failure to empirically validate the theories that have been developed; (6) the failure to allow for modification of existing theories; and, (7) the failure to develop theory from and relate theory to clinical practice.

Abstract

ABSTRACT

This paper identifies and describes seven areas of difficulty in the development, use, and testing of nursing theory. These problems are as follows: (1) the belief that there are absolute truths about nursing and that these truths can be found; (2) a lack of understanding of the definition and functions of theory; (3) the notion that there is only one theory of nursing and that this theory can account for all nursing activities; (4) the belief that members of the profession must all agree on the theory or theories that should be used; (5) the failure to empirically validate the theories that have been developed; (6) the failure to allow for modification of existing theories; and, (7) the failure to develop theory from and relate theory to clinical practice.

Since the 1950s, nursing has been keenly aware of the need to justify its existence as a distinct profession; one which stands apart from both the social sciences and the other health care disciplines. Nursing has realized that in order to accomplish this goal, it must develop a body of knowledge and theories which are unique to nursing and nursing practice. To some nursing leaders, the development of theory is considered to be the most important task currently facing the profession (Chinn & Jacobs, 1978; Donley, 1980). Once nursing theory has been articulated, a body of nursing knowledge can be developed systematically through the conduct of research that is guided by this theoretical framework.

Over the last two decades, there have been numerous attempts to help the profession achieve these goals. The American Nurses' Association and other professional organizations have sponsored conferences that focused specifically on issues relating to theory development. Nursing journals have published numerous articles on topics such as the need for nursing theory, methods that can be used to develop nursing theory, and descriptions of the characteristics of a good nursing theory. In addition, several nurses have developed and published theories of nursing.

Despite these efforts, at this point in time nursing still lacks a strong theoretical basis for the conduct of research, the development of knowledge, and the guidance of clinical practice. The topics of nursing theory and theory development are frequently controversial subjects. Responses to existing nursing theories range from absolute rejection to fanatical adherence to the ideas which have been set forth. In all, a portrait of the profession at this point is one of confusion and lack of concensus. Consequently, it is not difficult to be critical of the current state of the art of theory development in nursing.

However, a basic premise of this paper is that the confusion, ambiguity, and dissatisfaction with the current state of the art in theory development is a normal phenomenon in the growth of any discipline. Part of nursings frustration with theory development is a result of unrealistic expectations of the quality and amount of theory which could be generated after only 30 years of effort. This is not to suggest that the profession should cease its efforts, sit back, and allow nature to take its course. Rather, perhaps it is time that the profession temporarily redirect its efforts and attempt to identify the specific difficulties encountered by nurses when they attempt to develop, use, and test theory. Once the obstacles to achieving a proper theoretical orientation are identified, then the profession can systematically plan activities to resolve or reduce these problems. In the long run, this effort may prove to be a more efficient and effective use of the profession's limited resources and energies.

The intent of this paper is to identify and describe several of the reasons that nurses have encountered problems in the development, use, and testing of theory. Seven areas of difficulty have been identified: (1) the belief that there are absolute truths about nursing and that these truths can be found; (2) a lack of understanding of the definition and functions of theory; (3) the notion that there is only one theory of nursing and that this theory can account for all nursing activities; (4) the belief that the members of the profession must all agree on the theory or theories that should be used; (5) the failure to empirically validate the theories that have been developed; (6) the failure to allow for modification of existing theories; and, (7) the failure to develop theory from and relate theory to clinical practice. Each of these difficulties will be discussed. Due to their interrelated nature, some problems will be discussed together under one heading.

The Belief in Absolute Truths

One of the obstacles to the development and use of theory in nursing is the belief in the existence of absolute truths. Just as early scientists searched for absolute truths and standards in the natural world, some nurses have attempted to find the one true definition of nursing and other absolute truths about the nature of nursing activities. However, in contrast to the early scientists who used theory to pursue the truth, some nurses believe that the absolute truths about nursing must be known before any theories about nursing or nursing activities can be developed.

There are two problems with believing in the existence of absolute truths. First, absolute truths or absolute knowledge may not exist (Laudan, 1977). However, the issue of whether or not there are absolute truths in nature or if there can be one absolutely true definition of nursing is a topic for philosophical debate. The second and more practical problem that arises from adhering to the belief in the existence of absolute truths is the notion that such truths, if they exist, can be found. In nursing, there is a feeling that if one is patient, if one looks hard and long enough, and if enough stones are turned over, the true definition of nursing will be found, and then the profession can proceed with theory development. Some nurses picture scientific discovery and theoretical formulation as moments of great revelation, analogous to the historic episode in which Archimedes, while bathing, suddenly realized the principle of specific gravity. Overwhelmed with excitement from the nature of his discovery, Archimedes ran naked from his bath through the streets of ancient Greece shouting "Eureka!" Unfortunately, most scientific knowledge and theories are not developed in this manner.

It is faulty to assume that theories of nursing will be readily developed once nursing is able to find the one true definition of what nursing is and what nurses do. Such thinking, in a sense, puts the cart before the horse. Theories are not developed from absolute truths. Rather, theory may be used to pursue the truth. More generally, however, theory is independent of any truth seeking endeavor. Instead, theories are instruments that are used in a variety of functions in the scientific activities of a discipline. Laudan (1977, p. 12) states that the primary purpose of science and scientific theories is not to search for the truth. Rather, science primarily functions to solve the important problems facing a discipline or a society at any given time. Scientific theories provide solutions to those problems (Laudan, 1977).

The Definition and functions of Theory

A theory can be defined as a "systematic abstraction of reality that serves some purpose" (Chinn & Jacobs, 1983, p. 2). The purposes of a theory are to "resolve ambiguity, to reduce irregularity to uniformity, to show that what happens is somehow intelligible and predictable" (Laudan, 1977, p. 13). In short, theories serve the important functions of describing, explaining, predicting, and controlling the events that are of interest to a discipline (Chinn & Jacobs, 1983).

Theories are instruments which enable scientists to systematically and objectively study reality. The use of theories allows scientists to identify and explore the problems and phenomena of interest in their respective disciplines. The ability to systematically identify the phenomena that are important to a discipline and to objectively study these phenomena make it possible for scientists to solve the problems that are pertinent to their field of inquiry. Progress in a discipline is measured by its ability to solve important problems (Laudan, 1977).

If the thesis that the purpose of science is to solve problems is accepted, then it can be understood that theories do not have to be developed from the truth or even relate to the truth to be useful. If nursing fails to use or test existing theories on the basis that these theories do not provide an absolutely true or accurate picture of nursing, then much of the utility of these theories will be lost. This is not to suggest that theories should not be evaluated by some criteria before they are used. The minimum evaluation of a theory should include a critique of its clarity, consistency, logical development, adequacy, utility, significance, and capacity for discrimination (Stevens, 1979). Although additional criteria can be used to evaluate theory (Stevens, 1979), it is not evaluated on the basis of absolute truths. A theory may not present a completely accurate or comprehensive representation of reality and yet may still serve some purpose for the scientists who use it.

The history of science demonstrates that many useful theories, theories that enabled the various sciences to rapidly expand their bodies of knowledge, were based on assumptions that we currently believe to be false. Ptolemaic astronomy, developed in the second century A.D., enabled early astronomers to make reasonably accurate predictions about the motions of the planets, but it was based on the assumption that the planets and the sun revolved in a circular pattern around an earth which never moved. Although there were theories on the possibility of a heliocentric universe even before Ptolemy was born, until the 16th century no one could provide the mathematics that allowed predictions based on a suncentered universe to be as accurate as those of Ptolemy. For over 1300 years Ptolemy's theory, incorrect as it was, had been useful and had facilitated the development of a body of knowledge in astronomy.

Therefore, one of the most important features of theory that nursing must appreciate is that the profession does not have to precisely define the essence of nursing or identify the absolute truths about nursing activities before it can develop, use, and test theories. It is important to remember that "in order to act, it is not necessary to have a metaphysical belief that the rules by which we are acting are universal" (Bronowski, 1958, p. 70). In addition, "in appraising the merits of theories, it is more important to ask whether they constitute adequate solutions to significant problems than it is to ask whether they are 'true' " (Laudan, 1977, p. 14).

Three other features of theory must be understood if nursing is to make wise decisions in the development, use, testing, and evaluation of theory. First, and perhaps foremost, is that theory does not explain all of the phenomena or provide solutions to all of the problems in any area of inquiry. In every discipline, there are situations that do not fit into any known theory (Baer, 1979).

Secondly, theories themselves are not real, but rather, are abstractions of the real world (Chinn & Jacobs, 1983). As an abstraction, theory doee not describe the world in intimate detail. Rather, theory provides a systematic method by which to examine and describe the world (Christman, 1980). Nature and human behavior are too complex to be studied at random (Kuhn, 1970). Theory is a map to the exploration of the world; theories and paradigms guide the research that enables a discipline to develop a body of knowledge (Kühn, 1970). Nursing must realize that "conceptual approaches take a slice of the natural world and selectively construct a limited model of suggested reality for heuristic purpose" (Christman, 1980).

Finally, nursing must also realize that theory is dynamic, not static. Theory evolves in a discipline as old problems are solved and as new problems develop. While any model of nature is an approximation, and probably, no theory can completely explain or predict nature, theories improve as a science conducts research. Scientific research provides the means by which to validate, refute or modify theory. Research findings that validate or suggest modification of theories results in theories which provide clearer and more useful pictures of reality. These points are best summarized by Slichter (1958) who wrote:

A scientist should be the humblest of men. He soon teams that he dwells not in a world of reality but in a make-believe world. Reality is forever beyond him. He moves slowly toward it, but it ever eludes him (p. 101).

A portion of the frustration that nurses experience in the development, use, and testing of nursing theory is due to lack of understanding of the definitions and functions of theory. An explanation for this lack of knowledge is the manner in which nurses are educated. One problem is the diversity in the level of educational preparation of nurses, which ranges from the associate degree to the doctoral level (Jacobs & Huether, 1978). Although undergraduate students usually spend many hours of class time learning the basic sciences and basic nursing content, they usually are not required to learn about the history or philosophy of science. And, while nursing is itself a science, the ability to think critically and to generate knowledge are rarely taught at the entry level into practice. "Nursing courses, based on scientific theory and content, must be taught in such a manner as to enable the students to apply the scientific methods to practice" (Christman, 1980).

Similarly, although some theories of nursing are usually taught at the undergraduate level, the actual meaning of theories, how they are developed, tested, and used is frequently not fully explored until the masters or even the doctoral level of education. And, unfortunately, there is a shortage of doctorally prepared nurses (Jacobs & Huether, 1978). If nurses are to be capable of developing, using, and testing nursing theory, then they must be introduced to these topics at the entry level into practice - during their undergraduate education (Chinn & Jacobs, 1983). In addition, nursing education needs to promote the development of cognitive skills in research and philosophy (Jacobs & Huether, 1978) and nurses should be trained in the skills of conceptualization before reaching the graduate level of education (Dickoff & James, 1975).

Information on the development, use, and testing of nursing theory should also be made available to nurses who have already completed their basic nursing education. At the present time, unless nurses choose to return to graduate school, they frequently have little or no contact with nursing theories or nurse theorists. Seminars which focus on the issues of theory and theory development are frequently intended for the more academically oriented members of the profession, who have already had some exposure to the topic. In contrast, the continuing education programs that are available to practicing nurses frequently focus on specific health or clinical problems.

Similarly, nurse theorists need to publish their work in a wider variety of nursing journals, not just in publications that are intended almost exclusively for educators, theorists, and researchers. In 1981, the nursing journal with the largest circulation, Nursing 81 (McCloskey & Swanson, 1982), was a publication that primarily offered specific practice-oriented articles. While it is logical that practicing nurses may be primarily interested in practice-oriented topics, it is possible that nurses focus on these topics due to their lack of familiarity with theory. "Nurses who have had limited exposure to theory do not appreciate the importance of developing and using it" (Jacobs & Huether, 1978, p. 72). Information on theory must be disseminated to the profession at large and it must be presented in language that is understandable and in examples that are meaningful to practicing nurses.

One Theory of Nursing: Agreement On Which Theory Should Be Used

Once nurses develop a better understanding of theory and realize that absolute truths are not essential to theory development, the next obstacles to be overcome are the notions that (a) there is only one theory of nursing, (b) this theory can explain all nursing activities, and (c) all the members of the profession must agree on this theory. The effort expended by nurses searching for the one best and most comprehensive theory of nursing is second only to the quest for the Holy Grail.

One reason that nurses have experienced difficulty in attempting to develop a single theory of nursing is the nature of the phenomena that are of interest to nurses. Since 1860, when Florence Nightingale published the first book on modern nursing (Nightingale, 1969), nurses Have viewed man as a wholistic organism whose wellbeing is influenced by many factors other than just his physical state. Nurses have chosen to work with the wholeness of man and, as a result, their functions include a wide variety of activities that are intended to respond to or improve the diversity of human needs and problems.

While the wholistic approach to man is a predominant belief of nursing, it is very difficult to build a theory on such a belief (Kritek, 1978). Human beings are highly complex and frequently unpreditable organisms. Therefore, the situations encountered in a discipline that is committed to working with human problems and needs are inherently complex (Conant, 1967). In addition, many of the activities that are performed in the attempt to meet all of the needs of the human organism are not only difficult to describe, they are almost impossible to quantify. These problems create serious difficulties in theory development. However, since the wholistic belief of the profession is not likely to change, something must be done to facilitate the development of theory within the existing framework.

Some nurse theorists have attempted to reckon with the wholeness of man, and account for the multitude of nursing activities by developing grand theories of nursing. These theories attempt to account for all factors influencing the health of any person, all nursing activities, and all nurse-patient interactions. However, nurses encounter several problems when they attempt to use or test grand theories. First, such theories may appear to explain all of the events that are of interest to a discipline, but the theories are so broad that they are not useful in clinical practice (Jacobs & Huether, 1978). These theories are not precise enough to allow for the prediction or control of events (Jacobs & Huether, 1978). More importantly, it is difficult to evaluate the scientific value of grand theories (Hardy, 1978). Grand theories are not practical since they do not provide clear guides for clinical practice or the conduct of research (Hardy, 1978), Chinn and Jacobs (1978) wrote that "in seeking to endlessly extend boundaries and encompass the whole of reality, a discipline weakens the power of its scientific endeavors" (p. 8).

Other scientific disciplines do not have one grand theory that explains the totality of phenomena within their respective disciplines. Instead, there are usually multiple theories. These theories vary in scope and sophistication. Some theories are merely descriptive while others actually allow for the prediction or control of events. And, while these different theories are often used to describe, explain, or predict separate phenomena in a discipline, there are occasions when more than one theory can adequately describe, explain or predict the same phenomena. This pluralism of theories is accepted in other disciplines.

Although other disciplines do not have grand theories, and they accept pluralism of theories, the scientists in these disciplines do not appear to be as distressed or as insecure as nurses are about the progress and future of their respective sciences. Nursing views the inability to articulate and agree upon one comprehensive theory of nursing as failure to be a truly credible profession. Perhaps, given the feeling of insecurity as a distinct profession, nursing feels the need to have one agreed upon theory which should be used to structure curriculum, guide practice, and conduct research. Nursing does not seem to realize that it is almost impossible to capture the totality of a discipline's activities in one set of statements.

Instead of attempting to develop one comprehensive theory of nursing that is agreeable to all members of the profession, nursing should redirect its efforts to developing many theories of varying levels of scope and sophistication. While Jacox recommended that nurses should develop "middle-range" theories about certain limited aspects of nursing (Jacox, 1974), it is also acceptable for nurses to develop narrow, restricted theories. Similarly, it is important that nurses develop all levels of theory - descriptive, explanatory, predictive, and prescriptive - since nursing is an academic and a practice discipline (Donaldson & Crowley, 1978). Academicians use descriptive and explanatory theory to develop knowledge for its own sake while clinicians need predictive and prescriptive theory to predict and control clinical phenomena.

The development and testing of multiple theories of varying levels of sophistication and scope will probably result in the identification of more than one theory that is useful to nursing. Pluralism of theories is not synonymous with the presence of conflict and confusion in the profession. In fact, "pluralism of theories promotes productivity" (Donaldson & Crowley, 1978, p. 119). The existence of multiple theories provides a means by which nurses can test many models of reality and identify those that are the most useful to their specific area of practice (Donaldson & Crowley, 1978). Single theories are not as useful because they limit the scope of scientific inquiry (Donaldson, 1979).

There need not be concensus among members of the profession about which theory or theories are the most useful. While mass confusion is generally not productive, some conflict and the resulting dialogue can be healthy. However, the amount of disagreement and the lack of direction observed in nursing has led some members to believe that no meaningful work has been accomplished to date. This simply is not the case. The confusion and disagreement about nursing theory merely reflects the current phase of the profession's development as a science. Nursing is probably still in the pre-paradigm stage of scientific development (Hardy, 1978). At this stage of development, it is normal for a science to have ill-defined perspectives and little agreement about which theories are important (Hardy, 1978). Any science in the pre-paradigm state is characterized by divergent schools of thought, each of which has a different way of describing and interpreting the same phenomena (Hardy, 1978; Kuhn, 1970).

Nursing must learn to accept its growing pains as it moves through the process of developing into a mature science. The current state of the profession is merely a maturational crisis. It seems ironic that the profession lacks this insight when some of the theories that nursing has borrowed from other disciplines are developmental models. Due to its lack of familiarity with the history of science, nursing does not appreciate the fact that all sciences must progress through this stage of development. At certain points in time, even the basic sciences have experienced the lack of concensus and direction that nursing is currently facing (Hardy, 1978). It is easy to forget that Aristotle claimed that there were only four elements, and it was not until the late 17th century that Boyle defined the elements in the manner that is currently used in chemistry. Moreover, agreement has never been easy to achieve in any discipline. Although Priestley performed some of the original experiments that led to the discovery of oxygen, he continued to believe that it was phlogiston and not oxygen that was necessary for combustion. Upon seeing that other, mature sciences have taken centuries to refine their theories, theories which are still subject to modification and improvement, nursing should not be frustrated after only 30 years of attempting to develop and agree upon theory.

Nursing must also be careful to avoid prematurely agreeing upon and accepting a theory or theories of nursing. Nursing must attempt to develop and use a variety of theories. Decisions about whether or not theories should be accepted should not be made by a few leaders of the profession. A meaningful and useful theoretical framework will demonstrate its own merits after an adequate period of use and testing. In addition, premature agreement upon nursing theories could limit the scope of inquiry by ignoring other viable alternatives. "A science which orders its thoughts too early is stifled" (Bronowski, 1958, p. 45) while a science that continues to develop and test alternative theories is more lively, fruitful, and democratic (Baer, 1979). Hardy (1978) wrote:

Nursing cannot decree that a specific paradigm will be adopted; the adoption of a paradigm will be based on its scientific credence and its potential for advancing scientific knowledge in nursing (p. 40).

Failure to Empirically Validate and Allow for Modification of Theories

Two additional obstacles to the development and use of nursing theory are (a) the failure to validate existing theories, and (b) the failure to allow for modification of theories. The failure to validate theories is problematic for two reasons. First, nurses are responsible for providing safe nursing care and "because many phenomena in nursing directly or indirectly affect life and health, it seems particularly hazardous to develop nursing theory without empirical validation of proposed relationships" (Chinn & Jacobs, 1978, p. 6). Secondly, theory is used in practice to predict events and achieve desired outcomes (Chinn & Jacobs, 1978). If theories have not been tested against reality, the proposed relationships of a theory may not withstand the test of clinical practice.

While one method of validating theory is to use it in clinical practice (Chinn & Jacobs, 1983), if nurses are unaware that the theory has not been validated by research, they may become frustrated when they find that the theory is difficult to use or that it does not allow for the accurate prediction or control of events. However, existing nursing theories are difficult to validate because they are too unspecific and broad (Fawcett, 1978). Nursing must develop some theories that are clear and specific enough to allow deduction of testable hypothesis (Donaldson & Crowley, 1978).

Another problem that hinders progress in theory development is nursing's failure to realize that theories are not discovered, but are built. Theory is a process as well as a product. As a product, theories function in the realm of describing, explaining, predicting, and controlling the events in a discipline. Theories also serve the vital function of stimulating and guiding the research which contributes to the development of a body of knowledge. Equally important, the knowledge obtained through research can demonstrate the adequacy or the weaknesses and faults of theories. The discovery of the limitations or inconsistencies of a theory are what stimulate scientists to re-evaluate the theory. This process may lead to the modification of old theories or the development of new theories that allow for better explanation and more accurate prediction of events. As Kritek (1978) wrote:

Theory construction is, by nature, a self-perpetuating process. Each developmental step reveals both new deficiencies and new alternatives (p. 33).

Theory building is a dynamic and ongoing process which takes place over an extended period of time. Theories change with the development of new information (Christman, 1980) and as concepts evolve (Jacobs & Huether, 1978). By definition, theories must be subject to modification. Theories become counterproductive when used in an all or none fashion inasmuch as this limits the scientific process and causes "locked-in thinking" (Christman, 1980). In the quest for structure, some nurses have taken the work of a few theorists and treated it as dogma. Instead these theories should be used as starting points which need modification and refinement.

Failure to Develop Theory From and Relate Theory to Clinical Practice

The final obstacle to the development, use, and testing of nursing theory, is the failure to relate theory to clinical practice. Nurses have been frustrated when they attempt to use existing nursing theory in clinical practice. This frustration results from attempting to use grand theories as guides for clinical practice. These broad theories provide few clear or relevant guides to clinical practice (Jacox, 1974). Some authors have stated that theory should both begin and end in clinical practice (Dickoff & James, 1975).

However, grand theories are not inherently bad (Jacobs & Huether, 1978), nor are theories that are not directly relevant to practice. The articulation of concepts and their proposed relationships is partly a creative effort. Although theories which are very broad and unspecific may not be immediately useful, such grand theories can stimulate thought and provoke responses that lead to the development of theories that are specific, clear, and useful. In addition, grand theories can be viewed as a temporary method for organizing nursing knowledge. In any science, the decisions about what is important and the development of conceptual frameworks about those important issues, takes a period of time.

However, since the science of nursing entails professional clinical practice, theorists must attempt to develop some theories that are relevant to clinical practice. Theories should not only be logically and empirically valid, they must also be significant and useful to the profession (Hardy, 1978). Theories that are developed without consideration of clinical practice will have only a tenuous relationship to practice (Jacobs & Huether, 1978). Ideally, the theories which are developed in a practice discipline should have the following characteristics: (1) closely fit the area where they will be used; (2) be understandable to clinicians; (3) be general enough to be used in a wide variety of clinical situations; and, (4) allow clinicians to control or influence situations as they change over time (Glaser & Strauss, 1967, p. 237; Jacox, 1974, p. 11).

One method of achieving relevant theory is to develop theory from clinical practice. To avoid developing meaningless rules, this approach requires that observations of the real world be made before theory is developed (Bronowski, 1958). After a period of observing the phenomena in a discipline, the first step in developing theory is to specify, define, and classify the concepts which will be used to describe these phenomena (Jacox, 1974, p. 5). Next, statements are developed that propose how some of the concepts are related to each other (Jacox, 1974, p. 5). Finally, all of the statements or propositions can be related to each other in a systematic order (p. 5). However, each of the aforementioned steps require both time and trial. All sciences must experience a long period of observation and trial before observations and propositions can be systematically ordered (Bronowski, 1958).

Conclusion

The lack of a solid theoretical basis on which to develop knowledge, conduct research, and guide clinical practice is an important problem in nursing. This paper has identified several reasons why nurses have encountered difficulty in the development, use, and testing of nursing theory. While many of these problems normally occur as a discipline develops into a mature science, some problems can be resolved or minimized. This paper has suggested a few methods which may be helpful in the resolution of these problems.

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